MRI of the Hip - Assignment Example

MRI of the Hip Assignment Due: Q1. Femoroacetabular Impingement (FAI) can be an indicationfor MRI of the hip. Define and discuss this condition FAI is a condition of the hip that affects young and middle-aged adults. Femoroacetabular impingement (FAI) condition results to much friction at the place where by the femoral head and acetabulum come into contact with each other, hence leading to disruption of the hip joint. There are three recognized types of femoroacetabular impingement as shown in figure 1 below. Figure 1 Source: (Haacke, 1999) However, such damage might be experienced at the articular cartilege or the labral cartilage (Altay, 2002). The FAI condition comes in two forms that are the cam and pincer. The cam condition comes as a result of the abnormal contact of the head and the socket unlike the pincer condition that that is experienced at the front-top rim of the socket that eventually leads to the damage of the labral cartilage. This condition however is characterized by the areas where it damages including the cartilage, labral tears, early hips arthritis and the back pain. The result of the diagnosis of either form might lead to chondral lesions and labral pathology. Patients of these two conditions are presented with radiographs, CT and MRA. Consequently, this condition of FAI is being experienced by the high level athletes and people who are actively involved in sports. Traditionally, the hip pain in adults has been likened to the osteoarthritis in the joint. However, studies show that there are young patients with this disease that are referred to doctors without being diagnosed with arthritis. Additionally, the subtle bony and soft tissues problems can result to problems of the hip in young adults who are actively involved in sports (Andrews, 2000). It is stated that such problems might result to premature arthritis. However, with increased research, early diagnosis of the disease has been possible through the examination of hip impingement and radiological imaging through magnetic resonance arthrograpghy (MRA). While there is unclear literature regarding the cause of primary osteoarthritis, some clinicians’ believe that FAI might be the sole reason for the occurrence and progression of the condition in human beings. So, the FAI condition also results to abutment of the section between the proximal femur and the acetabular rim (Beck, 2004). The FAI condition can be treated through various means with surgery only being one of the choices. Others include through open or arthroscopic exploration of the hip in order to improve the femoral head neck junction. Q2. Discuss coil selection and describe how you would position a patient for MRI of hips Coil selection is the process of choosing coil elements for FAI diagnosis based on the size, construction, arrangement and performance of the coil (Borthakur, 2006). Coil selection method that is implied in choosing a set of coil elements for the diagnosis of FAI. Selection is done from a number of physical coil elements that are placed in an array and are used in performing of magnetic resonance imaging scan in a region that the clinician is interested in (Bencardino, 2002). The process of defining the anatomical boundaries for MRI gives a good choice for knowing which areas to include in radio frequency coil and planning of the pulse sequence. However, the process of designing of the coils relies entirely on a given task in mind but then adapt to their use in the clinical practice for imaging in several body parts. Patient positioning and the choice of the coil determine the quality of the image. However, in general terms the patient is examined for the supine and feet in the first place since this position can be tolerated well and can help in facilitating the positioning of the surface coils. It is clear from MRI studies that are performed at the hip can also be performed at the body parts or at the surface of the coil. However, the choice of the coil is necessary since this is used in case that there is a need for large anatomical regions to be looked at for instance during the assessment of the neoplastic or infective process or during the initial stages in the scanning process and followed by surface coil imaging (Conway, 1999). Thus in such a situation, the size of the FOV ranging from 32-48 cm is an indication of comparison for both hips. However a major setback here is the case where spatial resolution use which impacts the choice of coil use at certain body parts. MRI of the hips requires magnetic resonance imaging to know how the problem occurred. During this process, the person lies in a structure which is tube-like as seen in the figure below on positioning of the patient to allow the test to be performed. The head is put first before the feet since this is the way the machines are made. However, a loud sound would often be heard all through the testing process as the magnets move along to provide accurate imaging. The test usually takes 30 to 60 minutes. This is shown in figure 2 below. Figure 2: Positioning of the patient Additionally, as shown in the figure 3 below for the claustrophobic people they are not restrained to the little space and this makes the tube to be open. Source: (Goodman, 1997) Figure 3 The MRI machine has three parts that include the primary magnet, the gradient magnet and the coil which is the machine that is located nearest the part of the body that is being tested and in this case the hip. These parts work in conjunction with one another to send radio waves through the body resulting to a detailed image inside the hip. Afterwards the patient will be asked to remove all the metal jewelry and clothing. However in case there is any metal in the body this should be reported to the technician since some metals do not coincide with this test. As the MRI begins the patient has to be still for the resulting images to be clear. During the test there would be some loud sound knocking that would stop with time. If some of the patients have a difficulty to complete the 30 to 60 minutes required to finish the test, the doctor may provide some medication that the patient is required to take prior the test that would help in relaxation. In this case, the doctor should be told prior to scheduling the hip MRI for prescription purposes of the medication. Q3. "Tennis Elbow" is a common indication for elbow MRI. Define and discuss this condition Tennis elbow condition is a condition that damages a number of elbow structures (look at the figure below). Some of these structures are epicondyle, periosteum, bursa, tendons and muscles. This condition is as a result of heavy repeated contractions involving the wrist muscles (Ganz, 2003). The damage of the structures of the elbow comes as a result of stress that originates from the muscle and makes the microscopic to tear. However, the condition comes as a result of forceful and repeated contraction of the muscles that are positioned in the forearm and all the muscles there take part in the process. Figure 4: Classification of tennis elbow People who are often attacked by this disease are the working class people who need continuous and repeated movement of the forearm. Some of the jobs are those of carpentry or mechanics. Others include sporting activities such as golfing, skiing, throwing the ball, bowling and tennis. Other people who are prone to this condition are those people who are involved in using the wrist most of the times and frequent movement of the forearm. This condition is as a result of tissues undergoing stress which is chronic, and people suffering from this condition often experience pain in the epicondyles. The feeling progresses with time once the forearm and wrist are rotated. The elbow diagnosis is an inclusion of looking at ones history medical wise and observation of the symptoms. However, diagnostic testing might not be needed unless nerves are involved. There is no need for X rays since this condition affects the soft tissues (Goodman, 1997). Nonetheless, the use of the technology called MRI is critical in early diagnosis of the disease since it can show information on swelling and damage of tissues. Treatment of this condition includes the process of conservative. In this case, the use of ice or heat helps in relieving the pain that is caused by this condition. However, once the main symptoms have reduced, the use of heat helps in increasing the rate of blood flow in the body and hence healing. Some physicians might advise the patient for physical therapy where they might be encouraged to use ultrasound in the affected areas. The use of splint might proof to be important in helping reduce elbow stress over the daily duties. Exercises too are critical in order to improve the flexibility of the muscles and in reducing tendon stress which result in increased pull at the epicondyle (Hayes, 1996). Patients might also be advised to use non-steroidal drugs which are anti-inflammatory to take care of damage and pains of the muscles. The use of shock wave therapy has been common amongst the new methods of treatment of elbow tennis. This process involves directing sound to the injured tendon section. Shocks stimulate the growth of the blood vessels that were previously damaged in the healthy tissue. The use of therapy related to shock has been seen as a success in treatment of this condition but then has some side effects such as making the skin to look red or the occurrence of bruises in the skin (Kassarijian, 2005). Additionally, the use of toxin is being seen as an important process in the treatment of tennis elbow. This method has been found to reduce pain through making the muscles that were previously affected to be in a relaxed state (Medical imaging explanations, 2012). Q4. Discuss coil selection and describe how you would position a patient for MRI of an elbow Coil selection is a method that is implied in choosing a set of coil elements for the FAI. Selection is done from a number of physical coil elements that are placed in an array and are used in performing of magnetic resonance imaging scan in a region that the clinician is interested. The process of defining the anatomical boundaries for MRI gives a good choice for knowing which areas to include in radio frequency coil and planning of the pulse sequence. However, the process of designing of the coils relies entirely on a given task in mind but then adapt to their use in the clinical practice for imaging in several body parts (Kassarijian, 2005). In MRI elbow process, the patients are placed in the prone or supine positions while the arms are overhead. The process of imaging starts above the elbow about 10 cm. However, the images are got in the coronal and axial through the sagittal planes. Additionally, there is the performance of the coronal and axial TAW and SE imaging and the T2W or the STIR as shown in figure 5 here: Figure 5 The STIR photos/images demonstrate hyperintense fluid on the tendon of the biceps as shown in figure 6 below: Figure 6 Source: Kaplan (2001) The STIR shows a small collateral tear ligament. See figure 7 below: Figure 7 Source: Kwok (1999) Q5. Calcifying tendonitis of the rotator cuff is a common disorder a.) Calcifying Tendonitis Calcifying tendonitis is a usually asymptomatic condition in which macroscopic, poorly crystallized hydroxyapatite deposits are found on any of the tendons in the rotator cuff. Symptomatic patients, on the other hand, may complain of 1) Mild pain of the shoulder pain and tenderness radiating to the deltoid insertion or neck, with intermittent flares caused by arm elevation or lying on the shoulder, 2) difficulty in elevating the shoulder, loss of the shoulder’s range of motion or 3) severe and acute shoulder pain and tenderness. However, one cannot predict the deposit size based on the severity of symptoms, although symptoms usually present when deposits are bigger than about 1.5 cm (Kwok, 1999). b). Although the calcifying tendinitis of pathophysiology is being debated upon, the disease has been suggested to progress to four different stages based on their clinical features. The first stage, the formative phase, is characterized by the initiation and enlargement of calcium deposits on a tendon portion that has undergone fibrocartilaginous transformation. In the resting phase, the deposit neither increase nor decrease in size. Consequently, symptoms may be absent or available depending on the deposit size after the formative phase. Once the deposit illicit a reaction which is inflammatory, the disease enters the resorptive phase. Vascularization occurs around the deposit, and inflammatory cells are delivered to the site to soften the calcium deposits. At times however, the softened deposit leaks, causing severe pain. Finally, in postcalcific phase, the deposits are fully and resorbed (Das, 2002). Treatment of calcifying tendonitis depends on the phase of diagnosis. In detail, the resorptive phase, despite having the worse symptoms, is still self-limited. In fact, the condition may resolve spontaneously, no matter what phase, and is rarely associated with rotator cuff tears (Medical Imaging Explanations, 2012). Relieving management such as needling, aspiration and lavage may be done to resolve the accompanying symptoms. However, a patient may opt for surgery, especially when the symptoms are progressing, when conservative care cannot be given, and when it interferes with daily activities. In contrast, calcifying tendonitis in formative or resting phases may need extracorporeal shock wave therapy (ECSW), as lavage may not be as effective in these phases. If for some reason these procedures cannot be conducted, analgesics such as anti-inflammatory drugs that are nonsteroidal should be prescribed to provide pain relief (Romagnoli, 1999). c). X-rays which are plain of true anterolateral, lateral, anteroposterior (AP), axillary and supraspinatus should be able to detect cuff tendon calcification (Haacke, 1999). The appearance of deposit can vary depending on which phase the tendinitis is on. Formative and resting phases are characterized by localized, homogenous and well-delineated deposits, while diffuse, heterogenous, amorphous, fluffy, and poorly demarcated deposits are found in resorptive phase (Ito, 2001). Upon detection, deposits must be characterized by their location, especially the nearby tendons, and their size. Radiopaque arthrogram isn’t that important, but it can be done when there is an indication of rotator cuff tear. On the other hand, MRI is not necessary in diagnosing calcifying tendonitis, although it is more than 95% accurate in detecting calcifications. T1-weighted MRI of a calcific deposit reveals intensity decrease of the signals (Kaplan, 2001). Figure 8. Focal calcification on T2-weighted MRI image (red arrow). A similar hypodensity may be observed in rotator cuff. Source: (Seze, 2003). References Altay, T., 2002. Local Injection Treatment for Lateral Epicondylitis. Clinical Orthopedics, 398, pp. 127-130. Andrews, C. L., 2000. Evaluation of the Marrow Space in the Adult Hip. Radiographic, 20, pp. 27-42. Beck, M., 2004. Anterior femoroacetabular impingement: part 2. Midterm results of surgical treatment. Clin Orthop., 418, pp. 67-73. Bencardino, J., 2002. Imaging of hip disorders in athletes. Radiologic Clinics of North America, 40, pp. 267-287. Borthakur, A., 2006. Sodium and T1rho MRI for molecular and diagnostic imaging of articular cartilage. Radiologic Clinics of North America, 40, pp. 267-287. Conway, W., 1999. Hip. In: Magnetic Resonance Imaging. New York: Mosby. Das, D., 2002. Surgical Management of Tennis Elbow. Journal of Sports Medicine and Physical Fitness, 42, pp. 190-197. Ganz, R., 2003. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Rel Res., 417, pp. 112-20. Goodman, D., 1997. Subclinical slipped capital femoral epiphysis. J Bone Joint Surg., 79, pp. 1489-97. Haacke, E., 1999. Magnetic resonance imaging: Physical principles and sequence design. New York: Wiley & Sons. Hayes, C., 1996. Magnetic Resonance Imaging of the Musculoskeletal system II. The Hip, Clinical Orthopaedic., 322, pp. 297-309. Ito, K., 2001. Femoroacetabular impingement and the cam effect: a MRI based quantitative anatomical study of the femoral head neck offset. J Bone Joint Surg Br., 83, pp. 171-6. Kassarjian, A., 2005. Triad of MR orthographic findings in patients with cam-type femoroacetabular impingement. Radiology, 236, pp. 588-92. Kaplan, P., 2001. Musculoskeletal MRI. Philadelphia: Saunders Company. Kwok, T., 1999. A volume adjustable four-coil phased array for high resolution MR imaging of the hip. Magnetic Resonance Materials in Physics, Biology and Medicine, 9, pp. 59-64. Medical imaging explanations, 2012. Medical imaging explanations. London: The Institution of Engineering and Technology. Romagnoli, R., 1997. Magnetic Resonance Imaging of the hip. La Radiologia Medica, 93, pp. 150-155. Seze, M., 2003. Botulinum Toxin A and Musculoskeletal Pain. [in French] Annales de réadaptation et de médecine physique, pp. 329-332. Read More